Evaluation of the Relationship Between Colorectal Cancer Incidence and Colonoscopy: The Importance of Early Diagnosis

Abstract

Objective The present study evaluated the relationship between the incidence of colorectal cancer and colonoscopy in Santa Catarina from 2018 to 2022.

Methods Observational study of ecological type, which includes all confirmed cases of CRC in the state of Santa Catarina from 2018 to 2022, across health macro-regions. The data were obtained from SINAN, through TABNET/DATASUS. The variables gender, age group, race, type of care, average cost per hospitalization, days of stay, deaths, and mortality rates were evaluated.

Results In the period from 2018 to 2022, there were more than 28,000 cases of CRC in the state of Santa Catarina, with the Grande Oeste region being responsible for the highest incidence throughout the studied period. The main age group is between 70 and 79 years old; As for gender, most cases are predominantly male; about race, white ethnicity is predominant; the nature of service is, for the most part, elective; the average value per hospital stay is 2,355.41; total hospital stay days are 120,924; the number of deaths is 1553 and the mortality rate is (5.44/100.00). Regarding colonoscopy, the largest number of colonoscopies performed was in Grande Florianópolis.

Conclusion There is a high incidence of CRC cases in the state of Santa Catarina. Males and those aged 70 to 79 are the most affected by CRC in Santa Catarina. The Grande Oeste region has a higher incidence of cases compared with other health macro-regions.

Keywords

colorectal cancer - colonoscopy - epidemiology

Introduction

Colorectal cancer (CRC) is an invasive malignant neoplasm that develops in the colon and rectum mucosa and is mostly classified as adenocarcinoma. Early-stage CRC often presents as an intestinal polyp, which can take up to 10 years to evolve into CRC.[1] Advanced cancer stages show signs and symptoms such as rectal bleeding, palpable or visible abdominal or rectal mass through radiological exams, unexplained anemia, weight loss, and changes in bowel habits.[2]

CRC is the third most common cancer in Brazil for both sexes, following non-melanoma skin cancer, prostate cancer in men, and breast cancer in women. According to the National Cancer Institute (INCA), there are over 40,000 CRC cases annually in the country, with 17,000 deaths from colon and rectal cancer in 2020.[3]

Globally, CRC is the third most common cancer and the second leading cause of cancer death, with ∼18 million new cases and 881,000 deaths in 2018.[4] According to the American College of Gastroenterology (ACG), CRC is the third most common cancer among men and women and the second leading cause of cancer mortality in the United States, with 147,950 new cases and 53,200 deaths in 2020.[5] [6]

Preventive measures for CRC include physical exercise, maintaining a healthy weight, avoiding excessive alcohol and red and processed meat consumption, not smoking, and increasing fiber intake.[7] However, due to difficulties in implementing lifestyle changes, secondary prevention through screening tests has proven to be the most effective method to reduce CRC mortality.[8]

Colonoscopy is the gold standard diagnostic and therapeutic procedure for CRC screening and prevention.[9] This procedure allows for the removal of precursor polyps, reducing CRC incidence by 69% and mortality by 68%. Survival varies according to cancer stage, being over 90% in localized cases and less than 15% in advanced cases.[10]

Colonoscopy is a comfortable and safe procedure for the patient,[7] as it can be performed on an outpatient basis with rare adverse events. The perforation rate is 0.005% to 0.085%, and the post-colonoscopy bleeding rate is 0.001–0.687%.[10] A study conducted in Japan showed that the rates of hemorrhage, perforation, and fatal events related to colonoscopy were 0.0059%, supporting the safety of the exam.[11]

Screening colonoscopy for individuals aged 50 to 75 is recommended with an evidence grade A and should be repeated every 10 years.[1] However, in 2021, the United States Preventive Services Task Force (USPSTF) recommended starting CRC screening at age 45 for average-risk individuals due to the increasing incidence of CRC at younger ages.[6] [12] This change was also supported by the American College of Gastroenterology (ACG) and the American Cancer Society.[1] [6]

Regions with higher Human Development Index (HDI) have a higher prevalence of malignant colon and rectum tumors, such as the Southern region of Brazil. According to INCA, 70% of cancer cases in the country from 2023 to 2025 will be in the South and Southeast regions, with CRC prevalence in the South being 26.46 per 100,000 inhabitants.[13] This can be explained by greater exposure to risk factors such as sedentarism, obesity, a diet rich in red meat, smoking, greater availability of screening tests, and higher life expectancy compared with states with lower HDI.[4]

Early diagnosis and treatment of colorectal cancer positively impact patient prognosis and survival, achievable through effective, safe exams with few side effects and high therapeutic power like colonoscopy. This study evaluated the relationship between colorectal cancer incidence and colonoscopy in Santa Catarina from 2018 to 2022 to verify the efficacy of secondary prevention in the state's macro-regions. This study is justified to understand the distribution of cases in Santa Catarina, the profile of cases, their relationship with performed colonoscopies, and mortality, allowing a better understanding of cancer behavior in the state and the distribution and access to early detection and treatment services. The main objective is to evaluate the relationship between colorectal cancer and colonoscopy in Santa Catarina from 2018 to 2022.

Methods

An observational study with an ecological design was conducted, including all confirmed CRC cases in Santa Catarina from 2018 to 2022, through the health macro-regions. All confirmed CRC cases in Santa Catarina from 2018 to 2022 described in SINAN/DATASUS were included in the study through the studied variables. Additionally, data on colonoscopies from all state macro-regions were included. Cases with incomplete notification fields and those considered ignored by the database were excluded. Data were obtained from SINAN via TABNET/DATASUS at: https://datasus.saude.gov.br/informacoes-de-saude-tabnet/ . Data collection involved analyzing all described variables of confirmed CRC cases and colonoscopies, allowing the study's planned analyses. Studied variables included sex, age group, race/color, type of care, average cost per hospitalization, days of stay, deaths, and mortality rate.

As it was an ecological study using secondary data sources, informed consent was not required. The study presents minimal risk to participants, with no intentional interventions or modifications to participants' physiological, psychological, or social variables. Participants' benefits will be indirect, including seeking and clarifying information on colorectal cancer incidence in Santa Catarina from 2018 to 2022, comparing it with the number of performed colonoscopies.

Considering the study involved population aggregates, it does not fall under the terms of CNS Resolution 466/2012 and 510/2016 for evaluation by the Ethics Committee on Research Involving Human Beings – UNISUL. The authors acknowledge the content of CNS Resolutions 466/2012 and 510/2016, which serve as a reference for any necessary decisions for the study's execution.

The collected data were recorded in spreadsheets of the Microsoft Excel 2021 program (Microsoft Corporation, Redmond, WA, USA), and the calculations were performed using this tool. Descriptive epidemiology was used for data presentation, with qualitative variables expressed by absolute and percentage frequencies. For the calculation of incidence rates, data from the general population for the studied years and absolute numbers obtained, both from DATASUS, were used, divided by the population of the municipality, and multiplied by the constant 100,000.

Results

It is observed that, in the period from 2018 to 2022, there were more than 28,000 cases of CRC in Santa Catarina. The highest incidence is in the Grande Oeste region (676.46/100,000), while the lowest incidence is in the Grande Florianópolis region (134.22/100,000), as shown in [Table 1].

Table 1 Prevalence rate of colorectal cancer cases in the health macroregions of the state of Santa Catarina during the studied period

Variables	Morb CID-10	SUL	PLANALTO NORTE E NORDESTE	MEIO OESTE E SERRA CATARINENSE	GRANDE OESTE	GRANDE FLORIANOPOLIS	FOZ DO RIO ITAJAI	ALTO VALE DO ITAJAI	Total
Type		n (Prev.)	n (Prev.)	n (Prev.)	n (Prev.)	n (Prev.)	n (Prev.)	n (Prev.)	n (Prev.)
	Malignant neoplasm of the colon	1928(189,26)	1990 (138,33)	4838 (524,76)	5437 (676,46)	1650 (134,22)	1212 (165,63)	1537 (138,66)	18592,00
	Neopl malig junction rectum anus anal canal	1122 (110,14)	1186 (82,44)	2514 (272,69)	2645 (329,09)	852 (69,31)	591 (80,76)	1035 (93,37)	9945,00
Age group
	0 a 4 years	5 (7,61)	5 (4,83)	1 (1,53)	−	3 (3,98)	1 (1,91)	8 (11,18)	23,00
	5 a 9 years	7 (11)	−	−	3 (5,96)	5 (6,93)	−	4 (5,73)	19,00
	10 a 14 years	6 (9,82)	1 (1,08)	3 (5,28)	−	1 (1,39)	1 (2,14)	5 (7,18)	17,00
	15 a 19 years	6 (9,67)	74 (75,88)	17 (28,35)	−	43 (54,92)	7 (14,08)	11 (14,96)	158,00
	20 a 29 years	45 (28,73)	111 (47,68)	141 (98,36)	299 (232,01)	127 (66,26)	30 (24,78)	48 (26,92)	801,00
	30 a 39 years	209 (122,73)	240 (100,52)	352 (250,26)	214 (163,15)	179 (82,39)	119 (94,98)	176 (91,87)	1489,00
	40 a 49 years	349 (256,04)	453 (219,46)	929 (738,80)	711 (661,52)	325 (178,96)	291 (282,02)	303 (193,91)	3361,00
	50 a 59 years	702 (512,30)	755 (438,05)	1673 (1419,32)	1844 (1772,19)	543 (359,57)	453 (525,97)	631 (459,62)	6601,00
	60 a 69 years	969 (1009,77)	863 (744,69)	2269 (2749,00)	2681 (3626,35)	648 (591,94)	499 (853,63)	680 (737,24)	8609,00
	70 a 79 years	622 (1288,45)	494 (893,10)	1531 (3309,05)	1767 (4449,42)	389 (703,55)	333 (1203,25)	535 (1158,38)	5671,00
	80 years or more	130 (598,20)	180 (712,70)	436 (1996,70)	563 (2995,96)	239 (933,30)	69 (569,97)	171 (774,11)	1788,00
Gender
	Male	1642 (325,47)	1699 (236,77)	4084 (890,09)	4377 (1085,62)	1337 (222,28)	934 (259,56)	1455 (263,26)	15528,00
	Female	1408 (273,82)	1477 (204,86)	3268 (705,66)	3705 (924,94)	1165 (185,56)	869 (233,65)	1117 (200,98)	13009,00
Race
	White	2843,00	2963,00	7095	7600	2297	1569	2361	26728,00
	Black	120,00	41,00	23	67	81	23	44	399,00
	Brown	46,00	149,00	126	95	99	195	132	842,00
	Yellow	4,00	11,00	30	222	13	8	6	294,00
	Indigenous	0,00	0,00	0	5	0	0,00	2	7,00

Source: TABNET/DATASUS.

It is noted that, in Santa Catarina, the type of care for CRC is mostly elective (16,885 cases), except in the Planalto Norte e Nordeste regions and Alto Vale do Itajaí, where care is urgent (2,340 and 1,887 cases, respectively), as shown in [Table 2].

Table 2 Profile of colorectal cancer cases by type of care, average hospitalization cost, days of stay, deaths, and mortality rate in the state of Santa Catarina during the studied period

Type of care		SUL	PLANALTO NORTE E NORDESTE	MEIO OESTE E SERRA CATARINENSE	GRANDE OESTE	GRANDE FLORIANOPOLIS	FOZ DO RIO ITAJAI	ALTO VALE DO ITAJAI	Total
	Elective	2102	836	4354	6445	1462	1001	685	16885
	Urgent	948	2340	2998	1637	1040	802	1887	11652
Average hospitalization cost
	2018	2596,76	3105,74	2189,47	1549,77	2273,09	5192,07	3703,52	2413,69
	2019	2512,51	2590,83	1942,32	1589,88	2213,87	4635,15	3831,36	2368,2
	2020	3462,9	3767,12	1986,48	1422,67	2527,94	4218,51	3857,99	2488,4
	2021	3511,87	3665,46	1879,6	1397,61	2359,53	2879,15	3892,27	2320,13
	2022	3297,78	3581,27	1960,25	1430,43	2494,67	2025,89	3146,51	2202,28
	Total	2927,26	3307,73	1990,26	1471,1	2400,68	3256,45	3648,2	2355,41
Hospital stay days
	2018	3146	4029	4457	4057	4434	1045	1907	23075
	2019	2991	4103	4078	3803	4904	1584	2240	23703
	2020	1703	3833	4428	4021	5037	1101	1916	22039
	2021	1898	3026	4907	4748	4694	1659	2112	23044
	2022	1882	3826	6537	5504	5873	2686	2755	29063
	Total	11620	18817	24407	22133	24942	8075	10930	120924
Deaths
	2018	46	48	44	30	60	15	34	277
	2019	43	54	48	20	65	19	36	285
	2020	32	71	40	17	84	15	43	302
	2021	41	54	40	32	80	30	48	325
	2022	33	66	64	31	84	30	56	364
	Total	195	293	236	130	373	109	217	1553
Mortality rate
	2018	5,4	8,35	3,62	2,17	14,18	10,07	9,14	5,57
	2019	4,98	6,94	3,7	1,57	12,62	8,12	7,16	5,22
	2020	7,46	11,99	2,89	1,12	18,22	6,12	9,13	5,92
	2021	8,99	9,91	2,61	1,77	15,21	7,83	9,02	5,62
	2022	7,35	9,62	3,32	1,48	14,56	3,79	8,07	5,04
	Total	6,39	9,23	3,21	1,61	14,91	6,05	8,44	5,44

Source: TABNET/DATASUS.

In [Table 3], it is noted that the highest number of colonoscopies performed was in Grande Florianópolis (n = 22,723), while the Meio Oeste e Serra Catarinense region had the lowest number of colonoscopies performed (n = 9,847).

Table 3 Profile of patients who underwent colonoscopy in the state of Santa Catarina during the studied period

Procedure		SUL	PLANALTO NORTE E NORDESTE	MEIO OESTE E SERRA CATARINENSE	GRANDE OESTE	GRANDE FLORIANOPOLIS	ss	ALTO VALE DO ITAJAI	Total
	COLONOSCOPY	10986	20808	9847	15217	22723	12531	11586	103698
Type
	Elective	10910	20399	9721	13798	22300	12498	11497	101123
	Urgent	75	409	126	1419	423	32	89	2573
Gender
	Male	3962	7955	4115	6008	8040	4221	4587	38888
	Female	7024	12853	5732	9209	14683	8310	6999	64810
Age group
	Under 1 year	7	2	4	8	7	3	4	35
	1 a 4 years	1	2	8	4	1	−	2	18
	5 a 9 years	5	1	3	1	−	−	3	13
	10 a 14 years	7	10	6	9	1	6	5	44
	15 a 19 years	55	106	44	70	140	60	67	542
	20 a 24 years	108	232	96	206	325	167	148	1282
	25 a 29 years	199	310	155	290	519	275	258	2006
	30 a 34 years	268	522	227	429	659	418	322	2845
	35 a 39 years	468	864	392	629	1038	697	586	4674
	40 a 44 years	693	1238	572	906	1533	973	812	6727
	45 a 49 years	864	1739	793	1352	1956	1195	1111	9010
	(CONTINUE) 50 a 54 years	1422	2622	1236	1964	3108	1716	1600	13668
	55 a 59 years	1687	3251	1540	2414	3480	1858	1949	16179
	60 a 64 years	1751	3565	1614	2255	3488	1854	1744	16271
	65 a 69 years	1513	2991	1348	1991	3057	1604	1446	13950
	70 a 74 years	1149	1922	1004	1391	1953	1022	877	9318
	75 a 79 years	516	909	540	841	965	459	436	4666
	80 years or more	273	522	265	457	493	224	216	2450

Source: TABNET/DATASUS.

Discussion

In the present study, it was observed that the highest incidence of CRC is in the Grande Oeste region, followed by the Meio Oeste e Serra Catarinense region, while Grande Florianópolis was the macro-region with the lowest incidence of CRC. A Brazilian study conducted in Aracaju, Sergipe,[13] indicated that, between 1996 and 2015, there were only 1,322 cases of CRC in the municipality. These findings corroborate the fact that states with higher HDI have more cases of colorectal neoplasia due to greater exposure to risk factors such as a diet rich in red meat, smoking, and a sedentary lifestyle, in addition to the presence of more diagnostic resources and greater access to health services. Given this fact, it is assumed that the studies converge regarding HDI and the development of CRC, especially as they pertain to urban centers and reference points in their states.

When observing the age variable, it is noted that there is a higher incidence in the age group between 70 and 79 years, except in Grande Florianópolis, where the highest incidence is in the age group of 80 years or older. Although the absolute number of cases is higher in other age groups, the incidence rate allows for such comparability. Furthermore, it is important to highlight a considerable increase in incidence from the age of 40 in the Meio Oeste and Serra Catarinense and Grande Oeste. A meta-analysis written by Kolb and collaborators[14] showed that the rates of advanced colorectal neoplasia in individuals aged 45 to 49 were similar to the rates found in individuals aged 50 to 59 (3.6% and 4.2%, respectively). A study conducted by Anderson and collaborators,[15] showed that the risk of developing CRC was similar among individuals aged 40 to 49 and those aged 50 to 59. Various studies indicate an increase in CRC incidence in adults under 50, highlighting the importance of initiating screening at earlier ages. Although there is a slight age difference, it is observed that the age groups for developing CRC are very close, ranging between 40 and 60 years. This information suggests that regardless of the age group, starting at 40 years old, it is necessary to pay attention to the emergence of CRC and possible investigations to identify cases early. Some age groups have unique characteristics related to the disease, emphasizing the importance of the physician's attention during anamnesis to risk factors and the likelihood of disease development in the patient.

When observing the sex variable, it is noted that there is a higher incidence of colorectal neoplasia in males across all health macro-regions of Santa Catarina. A global systematic analysis[16] showed that in 2019, men accounted for ∼57.2% of CRC cases. A review article[17] has shown that men have 1.5 times higher chances of developing CRC compared with women, across all age groups. It is suggested that men are more exposed to risk factors such as alcoholism and smoking, and they tend to seek medical services less often, which justifies these findings. Another hypothesis is the difficulty in accepting invasive examinations, especially in this specialty, which makes men more vulnerable compared with women.

In [Table 2], when analyzing the average cost per hospitalization, it is noteworthy that 2020 was the year with the highest average hospitalization cost in Santa Catarina. When examining the variable of hospital stay days, it is observed that 2022 had the highest number of hospital days in the state. These findings differ from the international literature, as highlighted by a systematic review conducted in China,[18] that during the COVID-19 pandemic in 2020 and 2021, the average hospitalization days for CRC-related surgeries were significantly higher compared with the average days during the same period in 2019. Additionally, a study conducted in Australia[19] estimated that a 6-month delay in CRC diagnosis led to an increase of 1.6 million dollars in healthcare costs during the year 2020. It is hypothesized that the COVID-19 pandemic caused diagnostic delays, consequently leading to an increase in advanced cancer cases, which raised healthcare expenditures and resulted in longer hospitalization periods. However, such a global pattern was not observed in the macroregions of Santa Catarina. Therefore, the importance of early diagnosis and prevention of CRC is emphasized once again.

When observing deaths, it is noted that from 2018 to 2022, there were 1,553 deaths in Santa Catarina, with the highest number of deaths occurring in the Grande Florianópolis region, totaling 373 deaths, and the lowest number in the Foz do Rio Itajaí region, with 109 deaths. Additionally, it should be highlighted that 2022 had the highest number of deaths, with 364 deaths. A study by Goodarzi and colleagues[20] showed that ∼60% of CRC deaths worldwide occur in countries with high or very high HDI. Furthermore, a study conducted in Mato Grosso[21] showed that from 2005 to 2016, only 1,492 deaths from CRC were recorded in the state. Considering this, the hypothesis is raised that Grande Florianópolis has the highest number of deaths due to its high HDI. Meanwhile, in regions with lower HDI, underreporting of cases and a lack of diagnostic resources are observed, resulting in fewer deaths accurately attributed to the disease. Additionally, it should be noted that regions with higher HDI exhibit more risk factors such as inadequate diet rich in red and processed meat, smoking, and physical inactivity.

When analyzing the mortality rate, it is noted that the highest rate was in Grande Florianópolis (14.91/100,000), while the Grande Oeste region had the lowest mortality rate (1.61/100,000). Additionally, it is important to highlight that 2020 had the highest mortality rate (5.92/100,000). A study conducted in England[22] showed that in 2020, due to the COVID-19 pandemic, there was a 16% increase in deaths from CRC in the country compared with the pre-pandemic period. A study conducted in Japan,[23] indicated that the risk of mortality in patients diagnosed with CRC in 2020 and 2021 was significantly higher than in 2018. It is observed that during the COVID-19 pandemic, there was a decrease in referrals for colonoscopies, imaging tests, and diagnoses, as well as an increase in inadequate, interrupted, delayed, or abandoned treatments for colorectal cancer, which resulted in a rise in mortality from this cancer.

When observing the number of colonoscopies performed, it is highlighted that the highest number of colonoscopies was in Grande Florianópolis, while the Meio Oeste e Serra Catarinense regions had the lowest number of colonoscopies. It is hypothesized that Florianópolis has more health resources and, consequently, greater access, to a higher number of health services and hospitals, making it a state reference for Santa Catarina for the performance of these exams. Furthermore, this may explain the higher number of cases in individuals aged 80 and older in Grande Florianópolis, as there is greater use of colonoscopy as a preventive measure for CRC.

When examining the variable of sex, it is noted that in all macroregions of Santa Catarina, most of the individual's undergoing colonoscopy are female. According to Ribeiro,[24] there is a predominance of female patients undergoing colonoscopy, accounting for 59%. A retrospective study conducted in Nigeria[25] indicated that many patients undergoing colonoscopy were male, representing 62.2%. It is observed that there are studies that both align with and diverge from the present study. However, it is noted once again that in Brazil, women are more concerned about their health and seek medical services more often than men. This finding may also explain the higher number of CRC cases among males in the state of Santa Catarina.

When examining age groups, it is highlighted that there is a higher concentration of colonoscopies performed in the age group of 55 to 64 years in Santa Catarina. According to Batista,[26] the average age of patients undergoing colonoscopy is 52 years. Another study conducted in Ethiopia[27] indicated that the average age of patients was 43 years. It is observed that in Santa Catarina, patients undergoing colonoscopy are of a higher age compared with other locations, and they do not follow the recommendations to start CRC screening at age 50, which may lead to an increase in cases of colorectal neoplasia in the state.

Conclusion

It is concluded that the state of Santa Catarina had 28,537 cases of CRC during the studied period. It is noted that there is a higher incidence in the age group between 70 and 79 years. In all health macroregions, there is a predominance of cases among male individuals and those of white ethnicity. The highest incidence of CRC in the state was in the Grande Oeste region (676.46/100,000), followed by the Meio Oeste e Serra Catarinense regions (524.76/100,000), while Grande Florianópolis had the lowest incidence of CRC (134.22/100,000). The average hospitalization cost during the analyzed period is R$ 2,355.41, the total number of hospital days is 120,924, the number of deaths is 1,553, and the mortality rate is 5.44/100,000 inhabitants. Regarding colonoscopy, the highest number of procedures was performed in Grande Florianópolis, while the Meio Oeste e Serra Catarinense regions had the lowest number of colonoscopies. Predominantly, the nature of care was elective, and the patient's undergoing colonoscopy were mostly female and in the age group of 55 to 64 years.

CRC is a serious public health issue, especially in regions with higher HDI and among male individuals. Therefore, early screening with colonoscopy should be encouraged to prevent this neoplasm, which is increasingly affecting younger populations.

Conflict of Interest

The authors declare no conflict of interest, no funding sources, and the study was not preregistered.

Authors' Contributions

TGS and KSM: Substantial contributions to the conception or design of the work, data collection, analysis, interpretation, writing of the articles, and final version to be published. All authors agree and take responsibility for the content of this version of the manuscript to be published.

Data Availability

Not applicable.

Research Funding

The research was conducted with the researchers' funding.

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Publication History

Received: 20 July 2024

Accepted: 24 October 2024

Article published online:
18 December 2024